UTMC pilots safety moves in wake of kidney fiasco

10/2/2012

BY IGNAZIO MESSINABLADE STAFF WRITER

The University of Toledo Medical Center is pioneering two safety measures inside the operating room for transplant surgeries as a result of an incident in August when a viable kidney was discarded before it could be transplanted.

Dr. Jeffrey Gold, UTMC chancellor and vice president for biosciences and health affairs, told the university’s board of trustees Clinical Affairs Committee Monday about the two efforts — one of which he called a unique pilot program.

“We are doing several things simultaneously — one we have already done,” Dr. Gold said after the committee meeting. “We purchased a very simple infrared motion detector and we mounted it directly next to the chilling device, this so-called slush machine.”

A slush machine is an apparatus that keeps the organ cool until it is transplanted.

A six-page report written for UTMC by Dr. Marlon Levy, surgical director, transplantation, at Baylor All Saints Medical Center in Fort Worth, revealed new details about the Aug. 10 surgery in which a kidney was removed from a Toledo man at the hospital and was supposed to be transplanted into his sister.

The organ was inadvertently discarded with medical waste by a part-time nurse, Judith Moore, who resigned Sept. 10. UTMC fired Melanie Lemay, a 30-year employee and full-time registered nurse who was the “RN circulator” in the operating room at the time of the incident.

According to disciplinary records released by UTMC last week, Ms. Lemay had relieved Ms. Moore in the operating room while Ms. Moore went on a lunch break. During that time, the patient’s kidney was removed, cleaned, and placed in the slush machine.

When Ms. Moore returned from her break, Ms. Lemay did not update her, the reports state, and Ms. Moore proceeded to remove the contents of the slush machine and flush them down a hopper where liquid waste is flushed into the hospital’s waste-collecting system.

Dr. Gold said the infrared sensor alerts everyone in the operating room with an alarm whenever someone gets close to the slush machine.

“We are still calibrating it and trying to make sure it is not a distraction,” he said. “We have used it for several transplants.”

The medical center’s living donor kidney transplant program has been under voluntary suspension since Aug. 10. The hospital is still performing transplants from cadaver organs, although Dr. Gold said those organs are being obtained from other sources rather than the hospital doing its own harvesting.

“The feedback that I have gotten is that the system works and it needs to be continually refined,” he said. “These devices are commercially available. They are used in retail shops and homes, and all we did was repurpose it.”

The second measure, which is still under construction, is a ring-shaped device that fits on top of the slush machine.

“It will fit directly on top of the slush machines and be held in place by magnets that will have a visual and auditory alarm that will go off if it is lifted,” Dr. Gold said.

The device was designed by university engineers and medical staff and is being produced by an outside firm.

“A slush machine has no top to it,” Dr. Gold said. “A sterile sheet would be placed on top and this would go around.”

The purpose would be to alert everyone in the operating room that someone is accessing the removed kidney.

Dr. Gold said the university would eventually seek to publish a medical journal article on the two measures and it could seek a patent on the device for the slush machine. He expects a prototype to be delivered to the medical center by Friday.

He mentioned the two measures during a 30-minute presentation that included details on renal transplants, the medical center’s history of safety, and an update on the hospital’s quality and safety

Records released to The Blade last week indicated that UTMC also instituted two policies in the weeks after the botched transplant. One stated that all contents of the operating room are to remain there “until the patient physically leaves the operating room following a surgical procedure.”

The other says staff members may take breaks during a procedure only after they have consulted with the attending surgeon.

New, higher-visibility donor kidney containers also are to be used during procedures along with donor kidney identifier signs that are to placed on the slush machine when a kidney is inside.

Officials have declined to comment on the status of the woman who was to receive her brother’s kidney, citing privacy laws and the family’s desire for privacy.

Contact Ignazio Messina at:

imessina@theblade.com

or 419-724-6171.

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